Integrating Clinical Systems and Health Information Management: Automation Using Internet-Based Tools
Traditional hospital data management does not use Internet technology, is fragmented
across departments, and is based on local repository architecture. The hospital
may have one or more repositories, but often these repositories do not communicate
nor consolidate data. The repositories serve as a source of data lookup, yet are
typically not designed with the messaging architecture necessary to route and
manage the flow of clinical data to and from the physician. Traditional HIS systems
seldom provide integration of physician workflow with the hospital information
management system.
In this paper, I will discuss how a hospital (or other health care delivery system) can automate the process of data flow starting with transcription voice files and progressing to include laboratory, radiology, and administrative data. By implementing automated clinical messaging across departments, the hospital can create automated workflow tools for its staff and affiliated physicians, as well as build a repository that can be used as both an inpatient and outpatient EMR.
It Begins with Transcription
Traditionally, hospital information management (HIM) departments have been tied to local providers for transcription services and limited in their ability to connect vendors and "customer" physicians into a smooth working system. Starting with the generation of voice files for the transcriptionist, HIM departments have been limited to large proprietary systems from three or four large vendors. These systems are expensive, and the proprietary nature of their files can make it very difficult for the hospital to change the method of voice capture or transcription. In addition, the proprietary "C" Phone (Controller Phone) technology used by non-local transcriptionists can generate additional long distance phone charges. Because of these technology and connectivity issues, the hospital is often forced to use local transcriptionists with high start-up and support costs.
Modern technology offers a solution with the potential for wider choice and significant savings. With the standardization of audio files to .wav and .mp3 formats, voice capture technology is exploding. Voice capture devices are now available from a number of common electronic vendors. The output from traditional proprietary systems can now be "normalized," converting voice formats into standard .wav files. ADT information can be added to ensure accuracy, and a single file format can be delivered to any transcriptionist to work on the file using standard Internet technology.
The Internet provides the next key technological change. Using the connectivity and automation made possible by the Internet, hospitals can connect to transcriptionists anywhere in the world. Transcriptionists can deliver data that can be integrated into the normal hospital information management process. In addition, the Internet provides the potential for physicians to access and sign transcriptions online. This process can be integrated into the physicians overall data management workflow (see below).
When text files are returned to hospitals (and physicians), clinical messaging technology allows patient names to be checked against medical record numbers to assure accuracy. Additionally, an address book incorporates appropriate delivery to physicians and hospital departments. Documents can be routed for editing and signatures. The HIM department is able to track the process each step of the way, and "copy to" lists can be fully automated.
The ability to manage the variable flow of transcription as well as broker that service across a very large transcription pool allows new Internet vendors to provide more efficient service at prices that significantly improve the hospital's bottom line. Utilizing clinical messaging technology to manage the flow of transcriptions allows the hospital to incorporate physician workflow into HIM department processes. In fact, transcriptions can be the first step to automating clinical data management across the hospital system.
Coordinating Data Management Across Hospital Departments
The same messaging technology that allows the unique identification of transcriptions with appropriate routing and delivery to physicians can be used for other clinical documents. Most hospital departments have independent delivery methods for clinical data. The laboratory, radiology, pathology, and administrative offices might all have their own process to courier, fax, or mail data. This process, along with transcription delivery, can be centralized so data from multiple departments can be delivered simultaneously by a method that is appropriate for each physician's office. Some may choose courier or mail, others fax, and others electronic delivery. By taking the electronic data feeds from various departments and linking them to a central address book and patient index, the hospital can centralize the delivery (and lookup) of clinical data.
Sick outpatients often have tests done in multiple departments. They may have pre-op blood work in the laboratory, X-rays in the radiology office, and dictations through the HIM department. Traditional delivery methods often have each item sent independently from each department. By centralizing delivery, the hospital can realize significant savings from reduced postage and courier costs. In addition, the "centralization" process creates an electronic database across all departments with controlled access to data, significantly reducing costly chart pulls. All documents can be grouped and printed by patient for streamlined chart assembly. As physicians move to accept electronic delivery, hospitals can further benefit from cost savings through reduction in paper, courier, and fax delivery.
Physicians also benefit. They get documents from several departments, grouped by physician and patient, ready for filing. In addition the data is available online. Modern Internet-based data management tools allow the physician to gradually migrate away from paper data management and lookup to Internet-based clinical repositories.
The integration of inpatient and outpatient clinical data management tools allows the physician's workflow to be integrated into the hospital's workflow process; online editing of transcription, electronic signatures, ordering, and data lookup become coordinated processes.
Improved Physician Workflow With Automated Data Delivery
As the hospital moves to electronic report management, they create a repository than can be used for both inpatient and outpatient needs. With cross department indexing, patients' data can be uniquely identified and appropriately grouped. Physicians can access inpatient and outpatient data from their office, home, hospital, or cell phone. The hospital saves money through fewer data inquiries and physicians benefit with instant access to current data across all hospital departments.
However, the greatest improvement in physician efficiency comes when electronic data storage is combined with clinical messaging technology. Just as businesses achieved efficiency by replacing memos with email messages, physicians can automate clinical processes when incoming data is available to be managed electronically. Clinical inbox management can be both automated and coordinated between physicians and staff. Incoming data can be tagged with instructions and annotations and transferred to staff for further action or filing. Automated processes can be established depending on data source or type.
For example, an incoming operative report can be edited and signed (with a return copy to the institution) and then forwarded to the billing staff for appropriate coding. When complete, the billing staff can further annotate and tag for filing. Normal laboratory results can be delivered to appropriate staff to notify the patient. Abnormal results in a work queue can be brought to the physician's attention for action.
While some hospital information systems provide online electronic data lookup, the key to improved physician productivity is the ability to "push" data into physicians' inboxes for action. This gives physicians a queue to manage their own copies of new data, and provides the institution with the ability to deliver reports that need action, such as transcriptions awaiting signature.
Hospital Sponsored Physician "EMR"
For more than 30 years, the Holy Grail of clinical automation has been the "Electronic Medical Record." However, despite the availability of such systems, few physician practices have moved beyond paper data management. Obstacles have included capital cost, network infrastructure, and training; however, the single biggest deterrent has been the lack of ubiquitous access to uniquely patient-identified, digital, clinical data. EMR vendors have attempted to circumvent this limitation by making the record "encounter-centric," where the MD enters all data at the time of the encounter. However, limited physician time prohibits this approach. The combination of vendor (hospital) digital data and Internet-based repositories provides the basis for a timesaving EMR for the physician.
Initially, physicians can use this repository to simply lookup data and manage the flow of new information. Inbox management can be expanded to include inter- and intra-office communication. Electronic data access can supplement, and in some cases replace, access to the traditional paper chart. Gradually, just as other businesses have with e-mail, physicians and their staff can completely automate the communication and data management processes. Further automation can be achieved with the addition of tools to manage orders and prescriptions, and though it may not completely disappear for some years, reliance on the paper chart for everyday work will greatly diminish.
By providing automated data delivery and Internet-based repositories, hospitals provide a service to their physicians while automating the process of data delivery. Physicians can take advantage of EMR type functionality with simple browser access to Internet repositories.
Summary
The Internet presents many alternative, cost-effective approaches for hospitals to conduct their business. The transition to Internet-based communication and automation starts naturally with the HIM department and transcriptions. The HIM department benefits the most from bringing physicians into the workflow process of editing and signing transcriptions, and an immediate return on investment can be realized. In addition, standardizing voice and transcribed files allows the hospital to outsource and broker the service across a large competitive base.
Combining the delivery of laboratory, radiology, and transcription into a centralized hospital process improves the efficiency of delivery, allows the hospital to customize the delivery according to the physicians' preference (electronic, paper, fax), and creates a combined clinical repository of data. Hospitals can then provide further service to their physicians and staff by adding EMR like automation tools to the data delivery and lookup process.
Automated clinical messaging solutions that deliver and manage clinical data offer far more than traditional repository-based clinical HIS systems. By capturing standard digital, patient-identified clinical data from source systems such as transcription, laboratory, and radiology, the hospital can automate the processes of data delivery, lookup, and management. It can improve the efficiency of reporting; leverage outsourcing of services such as transcription; provide automation tools for staff and physicians; and build inpatient and outpatient EMR functionality. Historically, health care has lagged behind other industries in leveraging information technology. The emergence of the Internet provides our industry with the ability to catch up and for the entire patient population to reap the benefits.
